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MEDICAL HISTORY

MEDICAL HISTORY

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MEDICAL HISTORY

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  1. MEDICAL HISTORY • U.S. 28 year old male, catholic, married, born on May 6, 1981, works as a tricycle driver since 2001, residing in Caloocan City with wife. • Chief Complaint: KNEE PAIN & SWELLING

  2. History of Present Illness 7 Yrs PTA • White scales of the scalp resembled dandruff when scratched (no consult) • Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face  consult at UST Dermatology OPD; punch biopsy: Psoriasis– medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus3x/day prn resolution of Symptoms 2 Yrs PTA • Reappearance of lesions • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen  temporary relief) • Gradual limitation of in the movement of digits • Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up 1 Yr PTA • Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs • Relieved by rest or sitting down

  3. 1 month PTA • Swelling of both knees with increasing severity of pain (no consult) 1 week PTA • Pain in the hips extending down to his ankles • More difficulty in ambulating 5 days PTA • Consulted an Orthopedic Surgeon in Marikina; was told to have excess fluid in knee joints & advised arthrocentesis (pt. opted not to) 4 days PTA • Fever [undocumented] (self-medication: Paracetamol temporary lysis of fever) • Persistence of pain and fever  consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management ADMISSION

  4. Past Medical History • (-) DM • (-) HPN • (-) Joint surgery • (-) history of trauma • (-) Allergy • Diagnosed with dengue fever (2nd year high school) • Excision of cyst at the back (2007)

  5. Family History • (+) Myocardial Infarction – father • (+) DM – father • (-) HPN • (-) stroke • (-) Psoriasis • (-) Cancer • (-) Arthrides

  6. Personal & Social History • Smoker: 16-22 y/o (1-2 sticks per day) • Occasional Alcoholic Beverage Drinker • Denies Illicit Drug Use • 3 past sexual partners, all protected

  7. Review of Systems • No wt. loss, no loss of appetite • No hearing loss, no nasal congestion, no cough • No dyspnea, orthopnea, cyanosis • No chest pain, palpitations • No abdominal pain, diarrhea, constipation • No dysuria, frequency, change in character of urine

  8. PHYSICAL EXAMINATION General Survey • Conscious, coherent, oriented as to time, place and person, not in cardio-respiratory distress Vital Signs • BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6 °C Skin • Warm moist skin, (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy

  9. HEENT • Pink palpebral conjunctivae, anictericsclerae, no naso-aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Neck • Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged Cardiovascular • Adynamicprecordium, AB at 5th LICS, MCL; no murmurs • All pulses full and equal Respiratory • Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes

  10. Abdomen • Flat abdomen, NABS, soft, nontender, no masses Musculoskeletal • (+) sausage-shaped 4th digit of the right hand • (+) swelling and tenderness, both knees, DIP 4th R digit of the hand, R ankle • (+) flexed 5th left digit and the 4th R digit of the hand • Cannot flex the PIP and DIP of the right 2nd digit of the hand

  11. Neurological • Conscious, oriented to person, place and time, can follow commands • GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL, V1,V2,V3 intact; intact hearing, can swallow, (+) gag reflex, can shrug shoulders, tongue midline on protrusion • Motor: MMT 5/5 on both UE; 4/5 on both LE, no atrophy • Cerebellum: no deficits, can do FTNT, APST, HTST • Sensory: no sensory deficits • DTRs: 2+ on the UE, LE not assessed • (-) Babinski; no nuchal rigidity

  12. SALIENT FEATURES • History of Psoriasis • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet • Gradual limitation of in the movement of digits • Pain and swelling in both knees (increasing severity of pain), limping, and pain when walking down the stairs (difficulty in ambulating); Relieved by rest or sitting down • Pain in the hips extending down to ankle • excess fluid in knee joints • Persistence of pain and fever • X-ray of leg: soft tissue swelling

  13. SALIENT FEATURES • (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy • (+) sausage-shaped 4th digit of the right hand • (+) swelling and tenderness, both knees, DIP 4th R digit of the hand, R ankle • (+) flexed 5th left digit and the 4th R digit of the hand • Cannot flex the PIP and DIP of the right 2nd digit of the hand